Laserfiche WebLink
Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS Generator iD Number 12.Paqe of 3.EmeTqqnqy Response Phoq�. 14.Manifest Tracking Number <br /> USWASTE MANIFEST 100731" 2362 <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 6.Trans y qg�r 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> i� <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Descdplion(including Proper Shipping Warne,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(it any)) No. Type Quantity WI.Nol. <br /> tu <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> � <br /> [ <br /> 1 <br /> ` <br /> ' <br /> y <br /> 15. GENERATORVOIFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper slflppir�g name,and are classified,packaged, <br /> marked and labeled1placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulaVions.If export siripment and I am the Primary <br /> Exporter,I certify that the contents of this consignment cordomri to the terms of the allachad EPA Acknowledgment of Consent. <br /> I osirtify that The waste minimlzation statement idenfified in 40 CFR 262,27(a)�lf I am a large quantity generator)or(b)(itl am a small quantity generator)is true. <br /> Gencrator's/011prors PrintecIfTyped Name Signature Month Day Y04 <br /> 16.IhIernallonal Shipments <br /> import to US. Export from U.S Port of entrylexit: <br /> Transporter slgnalure(for exports on�y): Date leaving US.: <br /> iX 17.Transporter Acknowledgment of Recefpt of Materials V <br /> LU <br /> Transl der 1 Printedfryped Name Signature Month Day Year <br /> 0. <br /> 18.Discrepancy <br /> 18a,Discrepancy Incfcation Space <br /> Ll Quantty Type Residue Partial Rejection Ll Full Rejection <br /> Manifest Reference Number! � <br /> I 8b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> I 8c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardDus waste treatment,disposal,and recycling systems) <br /> 20.Designated Facility Owner or Operator:Certificatlon of receipt of hazardous materimls covered by the manifest except as noted in Item 18a <br /> Prinledffyipecl Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> � <br />